When I decided to expand my psychiatric practice by offering Transcranial Magnetic Stimulation (TMS), the clinical case was obvious — an established, non-medication treatment option for patients who had not responded to antidepressants. What I did not fully anticipate was how expensive the learning process would become.
The mistakes below cost me thousands of dollars. None of them were clinical mistakes. All of them were business and implementation mistakes — and every one of them was avoidable.
Mistake 1: Falling in love with the equipment first
A TMS system is likely the biggest single check you will write for a service line. Purchase or lease, new or refurbished, service contracts, coil costs — the sticker price is only the beginning. I looked hard at equipment before I had a realistic cost and volume model, which meant early decisions leaned on vendor presentations instead of my own numbers. Model the total cost of ownership against conservative patient volume first. A beautiful machine in an empty room is a very expensive chair.
Mistake 2: Treating staffing as an afterthought
TMS is a high-frequency service: patients typically come in daily for weeks, every session needs a trained technician, and the prescriber is involved at key points such as motor-threshold determination. I treated staffing as something we would figure out as we went. What actually happened was scheduling bottlenecks, coverage gaps whenever someone was out, and a program that could not grow past the availability of one or two people. Design the staffing model — including backup coverage — before the first patient is booked.
Mistake 3: Building credentialing and prior authorizations after the fact
TMS coverage is criteria-driven, and payers expect specific documentation of a patient's prior treatment history. If credentialing, documentation templates, and the prior-authorization workflow are not built before launch, you risk delivering treatment you cannot get paid for. I had to retrofit the paperwork engine while patients were already in the chair. Build it first: eligibility checks, authorization tracking, documentation that supports medical necessity, and a denial-prevention process.
Mistake 4: Marketing before operations were ready
It is tempting to announce a new service the moment the machine arrives. But demand you cannot schedule well is worse than no demand — it burns the referral relationships you will need later. Get operations and billing running cleanly first, then turn on patient acquisition: referral partners, your website, and campaigns built for a service patients research carefully before choosing.
The order I would follow today
- Financial feasibility and a conservative volume model.
- Vendor evaluation with total-cost math.
- Credentialing and the prior-authorization workflow.
- Staffing, space, and scheduling design.
- Documentation and EHR build.
- Referral network and marketing launch.
None of this is a reason not to add TMS — it remains a valuable service for the right patients. It is a reason to sequence the build correctly. That sequencing is exactly what I now help other psychiatric practice owners do.
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